According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a 

valid OMB control number. The valid OMB control number for this information collection is 0579-0047. The time required to complete this information collection is estimated to average .17 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 

OMB APPROVED

0579-0047

EXP: 01/2027

HERD OWNER (LAST NAME, FIRST NAME, MI) 

FEDERAL FEE BASIS STATE (Owner’s EMPLOYEE (Federal) COUNTY expense)

I CERTIFY: 

That I have drawn blood samples from each animal identified below and have

correctly listed each tube number with corresponding identification number, all 

numbers and letters of all eartags have been listed, cattle with existing 

official eartags have not been retagged, and when payment is claimed at 

program expense in accordance with agreement number below, no payment

YES NO has been or will be received from any other source. 

NO. IN HERD 

 

 

 

 

I I I I I 

□ □ □ □ 

□ □ 

□ □ 

□ □ □ 

□ □ 

I 

I 

I I 

STKTE

ZOUNTY ZO/E

HER/qNUMkER VETqZO/E TOTKL REK SUS

PREMISES I/qNUMBER ROUTE-STREET-ROK/ ZERTIFIZKTIONqFORqPKYMENT

PRIVKTE

POSTq OFFIZE STKTEq ZIPqZO/E

REKSONqFORqTESTq INITIKLq RETEST GPSqZOOR/INKTES

Slaughter (

Rea 

HdYqZertSq :

Validation

LvstYq MktYq )

Rea 

V

SIGNKTURE KGREEqZO/E

ROUTEPSTREETPROK/ /KTEqkLE/

N

POSTqOFFIZEq STKTEq ZIPqZO/E FIEL/qTESTq

REMARKS LKkORKTORY

PLKZE /KTE Rec'd KGREEqZO/E

/KTEqTESTED kYQ LABORATORY RESULTS

TESTq

NEGATIVE 

Susp. Ring 3 

Test Area Test 

SUS4 PECT 

Diagnostic

9 

Epidemiology KIND OF HERD 

DAIRY BEEF MIXED 

SWINE OTHER (Specify below) REACPvt TOR . Sale Other 10 

(Specify below) DONE BY: 

TOTAL REACTORS TAGGED AND BRANDED 

DATE: SIGNATURE: 

IN -

TERP 

REMARKS

AND 

ADDITIONAL

INFORMATION

REACTOR

TUBE TAG NUMBER

NUMBER 2 VACC 

TATTOO 

AGE BREED SEX RAP BAPA CARD FPA 

∆mP 

CF OTHER

VS FORM 4-33 

JUNE 2014

FIELD TEST 

CODE

N – Negative 

P – Positive 

TEST INTERPRETATION

N - Negative Classified By/Date

S - Suspect By: ______________

R - Reactor Date:_____________

TEST

AUTHORIZATION 

EXPIRES 

ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION

COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM

BRUCELLOSIS TEST RECORD

SUMMARY

PREVIOUS

TEST DATE

COMPLETE HERD TEST OF ALL

ELIGIBLE ANIMALS

RECORD ALL IDENTIFICATION NUMBER(S)

RT - Retag

NA - Natural Addition 

PA - Purchased Addition 

AB - Aborter

Record ALL 

Eartag(s) and 

Tattoo(s)

Record ALL 

Legble

Characters

PostqMove y

Quar. Tes
Privacy Act Notice 

Veterinary Services – Brucellosis Information System and Brucellosis Recording and Reporting System 

Authority: 21 U.S.C. 111, 112, 114, 114a-1, 115, 120, 121, 125, 134a-134f and title 9, Code of Federal Regulations, part 51 and 

part 78. 

Purpose and Routine Uses: 

Routine uses of records maintained in the system, including categories of users and the purposes of such uses: 

1) Detecting the foci of infection to reduce the rate of spread of infection to new herds; 

2) Evaluating brucellosis program activities of State, Federal, and contractual personnel; 

3) Preparing mailing labels and preaddressed forms to enhance field activities; 

4) Evaluating program effectiveness; 

5) Detecting factors of epidemiologic importance in containing or eliminating foci of infected herds; 

6) Assuring that brucellosis indemnities are promptly and properly paid; 

7) Notification of livestock owners with the animals at high risk of exposure to brucellosis because of livestock movements or 

an outbreak of disease or presence of quarantined premises in a community; 

8) Referral to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility of investigating or 

prosecuting a violation of law concerning animal disease control and eradication, or of enforcing or implementing a 

statute, rule, regulation, or order issued pursuant thereto, of any record within this system when information available 

indicates a violation or potential violation of law concerning animal disease control and eradication, whether civil, criminal, 

or regulatory in nature, and either arising by general statute or particular program statute, or by rule, regulation, or court 

order issued pursuant thereto; 

9) Litigation by the Department of Justice when the agency, or any component thereof, or any employee of the agency in his 

or her official capacity, or any employee of the agency in his or her individual capacity where the Department of Justice 

has agreed to represent the employee, or the United States, where the agency determines that litigation is likely to affect 

the agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such 

records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation; provided, 

however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of 

the information contained in the records that is compatible with the purpose for which the records were collected; 

10) Use in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when the 

agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the 

agency in his or her individual capacity where the agency has agreed to represent the employee, or the United States, 

where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation 

or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the 

litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use 

of the information contained in the records that is compatible with the purpose for which the records were collected; and 

11) Response to a request from a congressional office from the record of an individual made at the request of that individual. 

To certain Federal and State animal health officials to conduct, analyze, and report on the progress of animal disease 

control or surveillance programs. 

Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede brucellosis 

eradication activities.